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Yui JC, Brodsky RA. Updates in the Management of Warm Autoimmune Hemolytic Anemia. Hematol Oncol Clin North Am 2022; 36:325-339. [DOI: 10.1016/j.hoc.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
BACKGROUND Primary autoimmune haemolytic anaemia (AIHA) is an autoantibody mediated condition characterised by a variable disease course. A myriad of immunomodulatory agents have been employed but there is a paucity of evidence to support their use or compare their effectiveness. OBJECTIVES To determine the effects of various disease-modifying treatment modalities in people with AHIHA. SEARCH METHODS We searched MEDLINE (Ovid) (1946 to 2021), Embase (Ovid) (1974 to 2021), Latin American and Caribbean Health Sciences Literature (LILACS) (1982 to 2021), and the Cochrane Library (CENTRAL). Clinical trial registries and relevant conference proceedings were also reviewed. Records were included as of 7 March 2021. We did not impose any language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing immunosuppressive or immunomodulatory treatments against no treatment, placebo, or another immunosuppressive or immunomodulatory treatment, for people of all age with idiopathic AIHA. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. The prioritised pre-defined outcomes included complete haematological response at 12 months, frequency of adverse events at two, six and 12 months, partial haematological response at 12 months, overall survival at six and 12 months, relapse-free survival (RFS) at six and 12 months, red blood cel (RBC) transfusion requirement after treatment at 12 months, and quality of life (QOL) as measured by validated instruments at 12 months. Based on data availability, we were only able to perform meta-analysis on frequency of complete haematological response. MAIN RESULTS Two trials were included, enrolling a total of 104 adult participants (96 randomised) with warm AIHA in the setting of tertiary referral centres, both comparing the effectiveness between rituximab (375 mg/m2 weekly for four weeks, or 1000 mg for two doses two weeks apart) plus glucocorticoid (prednisolone 1.5 or 1mg/kg/day with taper) and glucocorticoid monotherapy. The average age of participants in the two trials were 67 and 71, respectively. One of the included studies had good methodological quality with low risk of bias, whereas the other study had high risk of performance and detection bias due to lack of blinding. Compared with glucocorticoid alone, adding rituximab may result in a large increase of complete response at 12 months (n = 96, risk ratio (RR) 2.13, 95% confidence interval (CI) 1.34 to 3.40, GRADE: low-certainty evidence). Rates of adverse effects at prespecified time-points were not reported. Limited data on partial haematological response were reported. The evidence is very uncertain about the effect of adding rituximab to glucocorticoids on partial haematological response at 12 months (n = 32; study = 1; RR 3.00, 95% CI 0.13 to 68.57; GRADE very low-certainty evidence). RBC transfusion need at 12 months was reported in one study, with four participants (mean number of packed red cell units 4.0 ± 2.82) from the rituximab group and five participants from the placebo (corticosteroid only) (mean number of packed red cell units 5.6 ± 4.15) group requiring transfusion, indicating very uncertain evidence about the effect of adding rituximab to glucocorticoids (n = 32, RR 0.80, 95% CI 0.26 to 2.45, GRADE very low-certainty evidence). The other study did not report transfusion requirement at prespecified time points but reported no difference in transfusion requirement between the two groups when comparing responders from enrolment to end of response or to the end of study follow-up (34 units versus 30 units, median [range]: 0 [1 to 6] versus 0 [1 to 5], P = 0·81). Overall survival and RFS rates at prespecified time-points were not explicitly reported in either study. Data on QOL were not available. AUTHORS' CONCLUSIONS Available literature on the effectiveness of immunomodulatory therapy for primary AIHA is restricted to comparison between rituximab plus glucocorticoid and glucocorticoid alone, in patients with newly diagnosed warm AIHA, calling for need for additional studies. The current result suggests that combinatory therapy with rituximab and glucocorticoid may increase the rate of complete haematological response over glucocorticoid monotherapy.
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Affiliation(s)
- Anthony Pak-Yin Liu
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Daniel Kl Cheuk
- Department of Pediatrics and Adolescent Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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3
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Abstract
Autoimmune hemolytic anemia is an acquired autoimmune disorder resulting in the production of antibodies directed against red blood cell antigens causing shortened erythrocyte survival. The disorders can present as a primary disorder (idiopathic) or secondary to other autoimmune disorders, malignancies, or infections. Treatment involves immune modulation with corticosteroids and other agents.
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Affiliation(s)
- Howard A Liebman
- Jane Anne Nohl Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
| | - Ilene C Weitz
- Jane Anne Nohl Division of Hematology, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Affiliation(s)
- Anthony Pak-yin Liu
- The University of Hong Kong, Queen Mary Hospital; Department of Pediatrics and Adolescent Medicine; 102 Pokfulam Road Hong Kong China
| | - Daniel KL Cheuk
- The University of Hong Kong, Queen Mary Hospital; Department of Pediatrics and Adolescent Medicine; 102 Pokfulam Road Hong Kong China
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5
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Affiliation(s)
- Peter Jacobs
- from the University of Cape Town Leukaemia Centre and Department of Haematology, Groote Schuur Hospital, Observatory 7925, Cape, South Africa
| | - Nicolas Novitzky
- from the University of Cape Town Leukaemia Centre and Department of Haematology, Groote Schuur Hospital, Observatory 7925, Cape, South Africa
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6
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Wang SW, Cheng TT. Systemic lupus erythematosus with refractory hemolytic anemia effectively treated with cyclosporin A: a case report. Lupus 2016; 14:483-5. [PMID: 16038113 DOI: 10.1191/0961203305lu2090cr] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
A 51 year old woman with systemic lupus erythematosus (SLE) serially developed thrombocytopenia, arthritis, lupus nephritis, pleuritis, mesenteric vasculitis and refractory hemolytic anemia during the past 19 years prior to presentation. The woman had been managed with high doses of prednisolone, splenectomy, methylprednisolone pulse therapy and cytotoxic drugs, including oral cyclophosphamide, azathioprine, mexotrexate and monthly parenteral cyclophosphamide for hemolytic anemia. After two months of therapeutic trial with Cyclosporin A (CsA) (3 mg/kg), the follow-up hemoglobin (Hb) level was increased to 12.0 gm% and the dose of prednislone was reduced to 5 mg every other day without occurring rebound during the subsequent three months. There were no obvious side effects from the medication.
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Affiliation(s)
- S W Wang
- Section of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Chang Gung Memorial Hospital, Kaohsiung, Taiwan, ROC
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7
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Michel M. Classification and therapeutic approaches in autoimmune hemolytic anemia: an update. Expert Rev Hematol 2014; 4:607-18. [DOI: 10.1586/ehm.11.60] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Jaime-Pérez JC, Rodríguez-Martínez M, Gómez-de-León A, Tarín-Arzaga L, Gómez-Almaguer D. Current Approaches for the Treatment of Autoimmune Hemolytic Anemia. Arch Immunol Ther Exp (Warsz) 2013; 61:385-95. [DOI: 10.1007/s00005-013-0232-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2012] [Accepted: 04/26/2013] [Indexed: 11/28/2022]
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9
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Evidence-based focused review of the treatment of idiopathic warm immune hemolytic anemia in adults. Blood 2011; 118:4036-40. [DOI: 10.1182/blood-2011-05-347708] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
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Farruggia P, Macaluso A, Tropia S, Genova S, Paolicchi O, Di Marco F, D'Angelo P. Effectiveness of cyclosporine and mycophenolate mofetil in a child with refractory evans syndrome. Pediatr Rep 2011; 3:e15. [PMID: 21772952 PMCID: PMC3133497 DOI: 10.4081/pr.2011.e15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2011] [Accepted: 05/02/2011] [Indexed: 11/22/2022] Open
Abstract
Evans Syndrome is a rare autoimmune disease consisting of hemolytic anemia, thrombocytopenia and/or neutropenia. It may be associated with other autoimmune or lymphoproliferative diseases. Its course can be extremely serious and, rarely, even life-threatening; thus it represents a excellent treatment challenge for the pediatric hematologist. First line treatment consists of steroids and/or immunoglobulin; further therapy with rituximab, vincristine, cyclophosphamide and other immunosuppressive drugs can be considered in unresponsive patients. We describe a baby with refractory Evans Syndrome that was cured by prolonged administration of mycophenolate mofetil and remained disease-free for 4 years after the discontinuation of treatment.
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Affiliation(s)
- Piero Farruggia
- Pediatric Hematology and Oncology Unit, G. Di Cristina Children's Hospital, Palermo
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11
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The spectrum of Evans syndrome in adults: new insight into the disease based on the analysis of 68 cases. Blood 2009; 114:3167-72. [DOI: 10.1182/blood-2009-04-215368] [Citation(s) in RCA: 174] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Abstract
Evans syndrome (ES) is a rare disease characterized by the simultaneous or sequential development of autoimmune hemolytic anemia (AIHA) and immune thrombocytopenia (ITP) and/or immune neutropenia. To better describe the characteristics and outcome of ES in adults, a survey was initiated in 2005. The data from 68 patients (60% of them women) fulfilling strict inclusion criteria for ES are reported. The mean age at time of ITP and/or AIHA onset was 52 plus or minus 33 years, both cytopenias occurred simultaneously in 37 cases (54.5%). ES was considered as “primary” in 34 patients (50%) but was associated with an underlying disorder in half of the cases, including mainly systemic lupus, lymphoproliferative disorders, and common variable immunodeficiency. All patients were given corticosteroids, but 50 of them (73%) required at least one “second-line” treatment, including splenectomy(n = 19) and rituximab (n = 11). At time of analysis, after a mean follow-up of 4.8 years, only 22 patients (32%) were in remission off treatment; 16 (24%) had died. In elderly patients, the risk of cardiovascular manifestations related to AIHA seems to be higher than the ITP-related risk of severe bleeding. In conclusion, ES is a potentially life-threatening condition that may be associated with other underlying autoimmune or lymphoproliferative disorders.
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Kaufman M, Limaye SA, Driscoll N, Johnson C, Caramanica A, Lebowicz Y, Patel D, Kohn N, Rai K. A combination of rituximab, cyclophosphamide and dexamethasone effectively treats immune cytopenias of chronic lymphocytic leukemia. Leuk Lymphoma 2009; 50:892-9. [DOI: 10.1080/10428190902887563] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Abstract
The clinical course of patients with B-cell chronic lymphocytic leukemia (CLL) is often made complicated by autoimmune phenomena which mainly target the blood cells. Among them, the autoimmune hemolytic anemia (AIHA) is the most common form. On the other hand, it is believed that CLL is the most common of the known causes of AIHA. The source of any putative autoantibody (bystander nonmalignant cells or tumor cells) is not clear yet. Recently, it has been hypothesized that leukemic B-cells may also act as professional antigen presenting cells (APCs). With respect to the management of CLL-associated AIHA, steroids still represent the first-line treatment option. Intravenous immunoglobulin, immunosuppressive drugs, and splenectomy are also frequently used for steroid-refractory forms. Furthermore, although the case series is still too small, encouraging data is now supporting the use of monoclonal antibodies, in particular anti-CD20 rituximab, in managing this often life-threatening autoimmune complication of CLL.
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MESH Headings
- Anemia, Hemolytic, Autoimmune/chemically induced
- Anemia, Hemolytic, Autoimmune/etiology
- Anemia, Hemolytic, Autoimmune/therapy
- Antineoplastic Agents/adverse effects
- Antineoplastic Agents/therapeutic use
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/etiology
- Leukemia, Lymphocytic, Chronic, B-Cell/therapy
- Models, Biological
- Vidarabine/adverse effects
- Vidarabine/analogs & derivatives
- Vidarabine/therapeutic use
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Affiliation(s)
- Giovanni D'Arena
- Hematology Oncology and Bone Marrow Transplantation Unit, National Cancer Institute, IRCCS Fondazione "G. Pascale", Naples, Italy.
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Bussone G, Hachulla E, Sibilia J, Michel M, Godeau B, Guillevin L, Mouthon L. Rituximab et traitement des maladies auto-immunes et inflammatoires systémiques. Presse Med 2009; 38:808-23. [DOI: 10.1016/j.lpm.2009.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2009] [Accepted: 02/05/2009] [Indexed: 11/17/2022] Open
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Bussone G, Ribeiro E, Dechartres A, Viallard JF, Bonnotte B, Fain O, Godeau B, Michel M. Efficacy and safety of rituximab in adults' warm antibody autoimmune haemolytic anemia: retrospective analysis of 27 cases. Am J Hematol 2009; 84:153-7. [PMID: 19123460 DOI: 10.1002/ajh.21341] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
To better assess the efficacy and safety of rituximab in adults' warm antibody autoimmune hemolytic anemia (wAIHA), we conducted a retrospective study including 27 adults (mean age 49.7 +/- 21 years) with either primary (n = 17) or secondary (n = 10) wAIHA. On average, the patients received 2.1 +/- 1.4 treatment lines before rituximab and six had undergone splenectomy. Five patients were resistant to corticosteroids, 16 had a corticosteroid-dependent wAIHA and six had relapsed after an initial remission. Overall, 25/27 (93%) patients achieved an initial response from rituximab (eight complete responses and 17 partial responses). During a mean follow-up of 20.9 months after rituximab, five of the responders relapsed, three of whom were successfully retreated with rituximab. Two mild infusion-related-reactions occurred, one patient had a rituximab-related severe neutropenia and one case of pneumocystis jiroveci pneumonia occurred in a severely immunocompromized patient. In conclusion, rituximab seems highly effective and relatively safe in adults with steroid-resistant or steroid-dependent wAIHA.
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Affiliation(s)
- Guillaume Bussone
- Department of Internal Medicine, Hôpital Henri Mondor, Assistance Publique Hôpitaux de Paris, Université Paris 12, Créteil, France
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Caractéristiques des anémies hémolytiques auto-immunes à anticorps « chauds » et du syndrome d’Evans de l’adulte. Presse Med 2008; 37:1309-18. [DOI: 10.1016/j.lpm.2008.01.026] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2008] [Accepted: 01/14/2008] [Indexed: 11/22/2022] Open
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17
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[Warm autoimmune hemolytic anemias and Evans syndrome in adults]. Rev Med Interne 2007; 29:105-14. [PMID: 17980462 DOI: 10.1016/j.revmed.2007.08.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Accepted: 08/15/2007] [Indexed: 12/23/2022]
Abstract
PURPOSE The outcome of autoimmune hemolytic anemia (AIHA) and Evans syndrome (ES) in adults is not well-known and their management is mainly based on empirical data. CURRENT KNOWLEDGE AND KEY POINTS The main characteristics of both AIHA and ES are reviewed in this article, based on the data available in the literature and on our experience. Although controlled studies and evidence-based data are lacking, some recommendations regarding the minimal workup useful to search for an underlying disease can be made as well as proposals for a better therapeutic strategy of both disorders. FUTURE PROSPECTS AND PROJECTS A better knowledge of the mechanisms triggering AIHA and ES as well as therapeutic trials are needed in order to better stratify treatment taking into account the promising efficacy of rituximab.
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Abstract
Red blood cell (RBC) autoantibodies are a relatively uncommon cause of anemia. However, autoimmune hemolytic anemia (AIHA) must be considered in the differential diagnosis of hemolytic anemias, especially if the patient has a concomitant lymphoproliferative disorder, autoimmune disease, or viral or mycoplasmal infection. Classifications of AIHA include warm AIHA, cold agglutinin syndrome, paroxysmal cold hemoglobinuria, mixed-type AIHA, and drug-induced AIHA. Characteristics of the autoantibodies are responsible for the various clinical entities. As a result, diagnosis is based on the clinical presentation and a serologic work-up. For each classification of AIHA, this review discusses the demographics, etiology, clinical presentation, laboratory evaluation, and treatment options.
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Affiliation(s)
- Bradley C Gehrs
- Department of Pathology, University of Alabama at Birmingham, USA
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Abstract
Treatment of autoimmune hemolytic anemias varies depending on whether the patient has autoimmune hemolytic anemia of warm antibody type, cold agglutinin syndrome, paroxysmal cold hemoglobinuria, or autoimmune hemolytic anemia secondary to an underlying disorder. Initial therapy for warm antibody autoimmune hemolytic anemia should be corticosteroids, such as prednisone at conventional doses of 1 to 1.5 mg/kg/d orally. Criteria must be established to determine whether the therapeutic response is adequate, because long-term therapy may lead to significant detrimental side effects. Splenectomy has the advantage over therapeutic options in that it has the potential for complete and long-term remission. The major adverse effect is the syndrome of overwhelming postsplenectomy infection. Other therapeutic options, which are less likely to have long-term benefit, are immunosuppressive drugs, danazol, intravenous immunoglobulin, and plasma exchange. Therapy of cold agglutinin syndrome often is unsatisfactory. All patients should avoid exposure to cold, and if additional therapy is necessary, the therapies used for warm antibody autoimmune hemolytic anemia may be tried with less likelihood of response. Paroxysmal cold hemoglobinuria requires aggressive supportive therapy, generally supplemented by corticosteroids. Hemolysis usually terminates spontaneously. Patients with secondary autoimmune hemolytic anemia may be treated similarly to those with idiopathic autoimmune hemolytic anemia, and additional therapy for the underlying disorder also may result in remission of the hemolysis.
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Affiliation(s)
- L D Petz
- StemCyte, Inc., Arcadia, California 91007, USA.
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Uçar B, Akgün N, Aydoğdu SD, Kirel B, Idem S. Treatment of refractory Evans' syndrome with cyclosporine and prednisone. Pediatr Int 1999; 41:104-7. [PMID: 10200147 DOI: 10.1046/j.1442-200x.1999.01004.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- B Uçar
- Department of Pediatrics, Faculty of Medicine, University of Osmangazi, Eskişehir, Turkey.
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Affiliation(s)
- L F Diehl
- Department of Medicine, Walter Reed Army Medical Center, Washington, D.C. 20307-5001, USA
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Ruess-Borst MA, Waller HD, Müller CA. Successful treatment of steroid-resistant hemolysis in chronic lymphocytic leukemia with cyclosporine A. Am J Hematol 1994; 46:375-6. [PMID: 8037200 DOI: 10.1002/ajh.2830460428] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Silva VA, Seder RH, Weintraub LR. Synchronization of plasma exchange and cyclophosphamide in severe and refractory autoimmune hemolytic anemia. J Clin Apher 1994; 9:120-3. [PMID: 7798158 DOI: 10.1002/jca.2920090205] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Two cases of severe autoimmune hemolytic anemia (AIHA) that failed multiple treatment modalities obtained complete and long-lasting remissions with a combination of three one volume plasma exchange (PE) on succeeding days followed 6 hours later on the 3rd day by cyclophosphamide (cyc) 750 mg/m2 IV, and cyc/prednisone (pred) qd tapering to either no therapy or minimal therapy over a 6 month period. Both cases remain without evidence of AIHA after 43 and 19 months follow-up. Possible non-exclusive mechanisms that explain this favorable outcome are enhanced cytotoxic effect of cyc on proliferating lymphocytes participating in the antibody rebound phenomena, suppression of B lymphocytes with daily cyc/pred, and/or formation of anti-idiotype antibodies.
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Affiliation(s)
- V A Silva
- Blood Bank, Washington University Medical Center, St. Louis, Missouri
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Abstract
Hemolysis can be induced by two general mechanisms. In the first one, erythrocytes lyse intravascularly due to complement fixation, trauma, or other extrinsic factors. In the second mechanism, which is the most common, the red cells are removed from the circulation by the mononuclear-phagocytic system either because they are intrinsically defective or because of the presence of bound immunoglobulins to their surfaces. The diagnosis of hemolysis is not difficult to establish and is based on the presence of anemia with sustained reticulocytosis in the absence of blood loss. Additional findings can include marrow erythroid hyperplasia; increased unconjugated bilirubin, LDH, and free hemoglobin; decreased haptoglobin and hemopexin; hemoglobinuria and hemosiderinuria; and decreased 51Cr red cell half-life. Hemoglobinemia, hemoglobinuria, and hemosiderinuria occur only in the setting of severe and rapid intravascular hemolysis. Conditions associated with significant lysis of red cells in the circulation include incompatible transfusion, G6PD deficiency, PNH, severe burns, and certain infections. The morphology of the red cell is abnormal in almost all cases of hemolytic anemia. However, the morphologic abnormality can be, in certain cases, diagnostic of the underlying condition. Treatment is usually supportive, with effective therapy directed to treat the underlying cause of hemolysis.
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Affiliation(s)
- I A Tabbara
- Department of Internal Medicine, George Washington University Medical Center, Washington, DC
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